FairShare evidence summary
Critical incidents associated with intraoperative exchanges of anesthesia personnel
Original source published:
The bottom line
In this classic incident analysis, intraoperative relief was more often protective than harmful — fresh eyes caught existing errors nearly three times as often as the handover process introduced them. It remains the foundational answer to the worry that breaks endanger patients. Practice and monitoring have changed enormously since 1982, so treat the direction of the finding as durable and the numbers as historical.
What the source found
Classic analysis of critical incidents associated with intraoperative exchanges of anesthesia personnel; relief was more often protective than harmful — relieving anesthetists discovered errors in 28 incidents while relief process contributed to error in only 10; none of the substantive negative outcomes caused by relieving clinician.
Limitations and applicability
Published 1982; practice patterns have changed substantially; pre-modern monitoring standards; retrospective incident reporting biases; small dataset.
Population and setting
Anesthesia providers (historical, tertiary hospital)
Used in FairShare guides
About this evidence
Research question / practical issue
How does this source inform Break Relief, Fatigue, and Safe Handoffs for the population it studied?
Study design, evidence tier, and source class
Peer Reviewed Critical Incident Analysis · primary source · evidence tier 2
Source type: Peer Reviewed Critical Incident Analysis · primary · Evidence tier 2
Topics: Break Relief, Fatigue, and Safe Handoffs
Audience: All Anesthesia Roles